Monitoring for Disease Recurrence in Multiple Myeloma
C. Ola Landgren, MD, explains his approach to monitoring patients with multiple myeloma for disease progression or recurrence.
PUBLISHED March 20, 2018
C. Ola Landgren, MD: At the initial presentation, your monoclonal protein was about 4.5 g/dL, and the biopsy that I had done for the bone marrow showed that almost 80% of the cells in the bone marrow were abnormal plasma cells. It was a pretty high number. You did not have any overproduction of light chains, so it was really this monoclonal protein. Then we started you on this 3-drug combination of bortezomib, lenalidomide, and dexamethasone. Immediately, we saw that the monoclonal protein went down. We gave you the second cycle and then the third cycle. And then, at the fourth cycle, the monoclonal protein almost plateaued out. It landed at around 1.4 g/dL. Because it went down by more than 50% from the initial point, that would be a partial response. We had this discussion of whether you should do a transplantation with melphalan or not. I said to you, “You had a high number of plasma cells at diagnosis, you had a quite high number of the protein, and now we have plateaued out.” I said, “I think the transplantation is probably the best thing for you.” So, together, we decided to do that.
Aurora Torres: Right.
C. Ola Landgren, MD: The transplantation was done, and you had a lot of toxicity from it. But the numbers went down—for the monoclonal protein. I think it went down to 0.2 g/dL. We did a biopsy, and it looked like a normal bone marrow—less than 5% of plasma cells. So, that really took away a lot of the disease cells. We had done the bone marrow before the transplantation, and it showed about 20%. So, it went from that 70% or 80% range down to 20% with the combination therapy. And then it went down to normal bone marrow after the transplantation. Those were the steps that we took.
The numbers never went down to 0 in the blood, so we couldn’t really look for minimal residual disease. The protein has to be 0 in order to look for those last cells. We could find some cells if we look with the more sensitive assays, and that’s why we also found this low-level protein.
You chose not to do maintenance because you didn’t want to do more therapy. We followed with blood tests, first, every month. Then we did this every 2 or 3 months, and the proteins were still about the same. Unfortunately, about a year later, they started to go up. You didn’t have any symptoms, at that time.
Aurora Torres: No, not at all. I didn’t have any symptoms. I was fine.
C. Ola Landgren, MD: I remember saying to you, “Unfortunately, this is something that can happen. The proteins can go up. But normally, you wouldn’t have symptoms.” You had no pain. You had no fatigue. You had nothing.
Aurora Torres: No.
C. Ola Landgren, MD: Then we talked about what that meant. Do we need to start you on therapy? If so, what therapy will that be? And you said that you didn’t want to do therapy unless you really had to.
Aurora Torres: Exactly.
C. Ola Landgren, MD: Another month later, we checked, again. It was about the same number. It was 0.2 g/dL or something like that. I remember that we checked this, multiple times. And next time, I think it was the same. It was 0.3 g/dL. You told me you didn’t want to do therapy. And so, we kept on checking. I think we kept on doing that until it was about 0.7 g/dL or 0.8 g/dL?
Aurora Torres: It was 0.8 g/dL.
C. Ola Landgren, MD: And I said, “We should probably think about starting therapy.”